The ‘first wave’ of COVID-19 created many challenges. Our hospital was fortunate to have slightly longer than many others to prepare. One of our Emergency Department (ED) challenges was that, as part of a redesigned process, patients with respiratory failure (presumed COVID-19) were to be assessed in a very different clinical area (single rooms instead of ‘open plan’ resuscitation room), managed by a much larger team of clinicians, using Level 3 (airborne) PPE and a modified approach to Rapid Sequence Intubation (RSI) induction of anaesthesia. Rapid cycle simulation and debrief has subsequently been described as part of a system-based learning approach during the COVID-19 pandemic 
The aim of this programme was to rapidly familiarize a large team with the new clinical environment and RSI process, using the learning conversation after each simulation to make an immediate change, as required, to the clinical area and/or process.
Each simulation was an identical clinical scenario, i.e. a patient with respiratory distress for whom the need for COVID-19 modified RSI had been identified. The simulation was delivered in the rooms that were subsequently to be used for direct clinical care of confirmed or suspected COVID-19 patients.
A process testing approach was taken. During the simulation brief, the process was talked through in detail (all expected actions and sequence), the team then performed the simulation, followed by a learning conversation that was very focussed on the challenges in delivering this process. Using mobile cameras and large screen TV, all simulations were live streamed to an immediately adjacent area, such that a large number of other clinicians could observe the brief, the simulated clinical scenario and participate in the learning conversation. Agreed changes in equipment, ergonomics and process were immediately incorporated into the next simulation. Once this area was required for direct patient care, an identical room was set up in an adjacent (non-COVID-19 clinical area) to allow daily simulated training to continue. On one occasion, where there was advance notice of the arrival of a patient requiring RSI, the team who were to be involved in the RSI ‘drilled’ this scenario (‘just in time’ simulation) whilst awaiting the arrival of the patient. It was observed that participants who had previously been less comfortable with simulation were happier with this process testing approach (knowing what is expected and with no surprises).